Midterm Study Flashcards
What is preconception health?
- Health of all individuals during their reproductive years, regardless of gender or orientation
- Starting at age of first menarche until menopause (1 year of no periods)
- Promotes healthy fertility and focuses on actions that individuals can take, regardless of plans to have children, to reduce risks, promote healthy lifestyles, increase readiness for pregnancy
- Comprehensive approach includes actions on an individual, community, and population level
- Health of parents, their lifestyle choices, and the environment in which they live before and during pregnancy have lifelong implications for their children’s health, learning, and behaviours
- Achieving a healthy pregnancy outcome is influenced by a woman’s health status, lifestyle, and history prior to conception
What are some of the benefits to preconception health care?
o Prevents pre-term births
o Improves birth weight
o Prevents congenital anomalies including neural tube defects
o Reduces infant mortality
o Reduces maternal mortality
o Lessens healthcare system burdens
What can preconception health include?
o Interventions that identify and modify risks to men and women’s reproductive health and future pregnancies
o Promotes health and prevents disease in women of reproductive age
o Improves pregnancy and birth outcomes
o Based on family-centered care principles
o Provides health promotion, screening, and interventions for women of reproductive age to reduce the risk factors that might affect future pregnancies
What is the purpose of preconception health?
o Identify health problems, lifestyle habits, or social concerns that might unfavorably affect pregnancy
o Promote health of the woman, baby, and family and to identify and modify risk factors that are known to influence pregnancy outcomes
What is included in a preconception health assessment?
- Reproductive history
- Environmental hazards and toxins
- Medications – teratogens
- Nutrition, folic acid intake, and weight management
- Genetic conditions and family history
- Substance use (i.e. alcohol and tobacco)
- Chronic diseases, communicable diseases, vaccinations
- Family planning
- Social support, domestic violence, and housing
What types of things would a nurse expect to counsel a patient on when it comes to preconception health?
- Health of parents impacts health of the child
- Identify/modify risk factors in individuals prior to pregnancy
- Identify patients at high risk for an adverse pregnancy outcome
- Risks after 35 years old
- Treatment of medical conditions and results
- Avoiding teratogens
- Cessation or reduction in problematic substance use
- Immunizations
- Exercise
- Referral for genetic counselling
- Referral to family planning services and/or family and social services
- Infectious disease testing (STI’s, Hep B, HIV/AIDS)
- Folic acid supplementation
- Stress management
What types of medical conditions should be tested/treated for during preconception health?
o Diabetes
o Obesity
o STIs
o Hypothyroidism
o Maternal phenylketonuria
What are risks of inadequate nutrition during pregnancy?
o Increase in number of low-birth-weight infants
o Increase in preterm infants
Why are women advised to maintain a folate rich diet and take folic acid supplements before they have conceived? When are they advised to increase intake?
Poor intake causes neural tube defects
o Neural tube begins to close within the first month, often before pregnancy
Supplements should be taken from 3 months prior to conception to 6 months postpartum.
What are some folate rich foods?
liver, beans, lentils, edamame
What childbearing concerns may affect obese women more than a woman at the ideal body weight?
o Infertility issues
o Difficulty maintaining pregnancy including increased risk of spontaneous abortion and recurrent pregnancy loss
o Still birth
o Gestational diabetes
o Preeclampsia/eclampsia
o Noninvasive prenatal testing that misses abnormalities
What are infants of obese mothers at an increased risk of?
o Undetected chromosomal abnormalities
o Neural tube abnormalities
o Heart, ventral wall, and cardiac defects
Why are obese patients more of an aspiration risk during pregnancy than mothers at the ideal body weight?
All pregnant patients experience
Delayed gastric emptying time
Decreased cardiac sphincter (between esophagus and stomach) tone
Hyperacidic gastric contents
These combined with the increased intragastric pressure and volume produced by obesity result in an increased risk of regurgitation and aspiration
What are some concerns associated with advanced maternal age?
o Advanced maternal age may be a risk factor for Down’s syndrome
o Declining fertility with advanced maternal age results in the need for assisted reproductive technologies and preterm delivery
o Multiples/c-sections
What are some concerns associated with advanced paternal age?
Decrease in serum testosterone
Infecundity (sterility)
Congenital anomalies
Adverse perinatal outcomes
o Genetic quality of sperm produced by older men may be reduced
What are some environmental factors that may affect preconception health?
o Education
o Workplace
o Income
o Physical environment
o Access to health service
What infections should be screened during the preconception health assessment?
o Vaccines for Hep B, Rubella, Varicella
o HIV/AIDS screening and treatment
o STIs screening and treatment
What is a postpartum infection? and what are the most common symptoms?
- Also called puerperal infections
- Any infection occurring within 42 days of birth or loss
- The most common symptoms are:
o Fever
o Tachycardia
o Localized pain
What are preconception or antepartum risk factors for postpartum infections?
o Malnutrition or obesity
o Concurrent medical or immunosuppressive conditions
o History of venous thrombosis, UTI, mastitis, pneumonia
o Diabetes mellitus
o Alcohol or substance misuse
o Anemia
o Preeclampsia
What are intrapartum factors that increase the risk of a postpartum infection?
o Caesarean or other operative birth
o Prolonged rupture of membranes or labour
o Internal fetal or uterine pressure monitoring
o Chorioamnionitis – infection of membranes and amniotic fluid
o Bladder catheterization
o Multiple vaginal examinations after membrane rupture
o Epidural anesthesia
o Retained placental fragments
o Postpartum hemorrhage
o Episiotomy or lacerations
o Hematomas
Describe postpartum endometritis including risk factors, signs and symptoms, diagnostics and management
- Infection of uterus lining
- Initially localized at placental site but then spreads
- Most common postpartum infection
Risk factors
o Caesarean
o Prolonged labour or membrane rupture
Signs and symptoms
o Fever, chill
o Tachycardia
o Anorexia, nausea
o Fatigue, lethargy
o Pelvic pain
o Uterine tenderness
o Foul-smelling, profuse lochia (vaginal discharge)
Diagnostics
o Leukocytosis
o Increased sed rate
o Anemia
Management
o Broad spectrum antibiotics (may be considered prophylactically)
o Hydration
o Rest
o Pain relief
Describe postpartum wound infection including risk factors, signs and symptoms, diagnostics and management
An infection of a wound caused by childbirth
Risk factors
o Caesarean
o Episiotomy or laceration
Signs and symptoms
o Fever
o Erythema, edema
o Warmth
o Tenderness, pain
o Seropurulent drainage
o Wound separation
Management
o Broad spectrum antibiotics (may be considered prophylactically)
o Appropriate wound care
Describe postpartum UTIs risk factors, signs and symptoms, and management
Risk factors
o Urinary catheterization
o Frequent pelvic examinations
o Epidural anesthesia
o Genital tract injury
o History of UTIs
o Caesarean birth
Signs and symptoms
o Dysuria, frequency, urgency
o Low-grade fever
o Urinary retention
o Hematuria
o Pyuria (WBC or puss in urine)
o Costovertebral angle tenderness or flank pain if upper UTI
Management
o Antibiotics
o Pain relief
o Hydration
Describe postpartum mastitis including progression, signs and symptoms, and management
- Most common 3-4 weeks after birth well after the flow of milk has been established
Progression
o Initial lesion is often an infected nipple fissure
o Ductal system becomes infected
o Inflammatory edema and engorgement of breast obstruct milk flow in the lobe
o Regional, then generalized mastitis follows
o Can progress to breast abscess if not treated promptly
Signs and symptoms
o Chills, fever
o Malaise
o Local breast tenderness, pain
o Swelling, redness
o Axillary adenopathy
Management
o Counselling about prevention of cracked nipples, incomplete breast emptying, and plugged milk ducts to prevent it from being an issue
o Manual expression or breast pump can be used to maintain lactation
o Intensive antibiotic therapy
o Local heat or cold
o Adequate hydration
o Analgesics
Describe the term antepartum
o Also called prenatal
o Time between conception and onset of labour
o Often used to describe the period during which a woman is pregnant
Describe gestation
o Number of weeks of pregnancy since the first day of the last menstrual period
Define the trimesters of pregnancy?
o First – first day of LMP through 12 completed weeks
o Second – 13 weeks through 27 completed weeks
o Third – 28 weeks through 40 completed weeks
Describe the field of obstetrics view of human development
o Pregnancy counts from the first day of the last menstrual period (LMP)
o Gestation lasts for 40 weeks (10 lunar months)
o The first 2 weeks of pregnancy correlate with development of the oocyte and endometrial lining
Describe the embryological view of human development
o Embryo count begins with oocyte fertilization (so different start dates)
o Gestation lasts for 38 weeks
What hormone are pregnancy tests detecting?
What is the progression of this hormones levels?
What can lower/higher numbers indicate?
Beta-hCG, or b-hCG, or hCG
o Production begins at implantation
o Can be detected about 8-10 days after fertilization
o Concentration peaks at 9-10 weeks
o Declines to a stable level after 20 weeks
Reduced levels indicate
Miscarriage
Abnormal gestation (i.e. Down’s syndrome)
Higher levels indicate
Molar pregnancy
Multiple gestation
What are presumptive signs of pregnancy? What are some examples of these?
o Subjective changes reported by the patient
o Symptoms can be caused by conditions other than pregnancy
Examples include
Amenorrhea
Fatigue
Breast changes
What are probable signs of pregnancy? What are some examples?
o Objective changes assessed by an examiner
o When combined with presumptive signs and symptoms, these changes strongly suggest pregnancy
Examples:
Hegar sign (softening of lower uterus)
Ballottement (rebounding baby)
Pregnancy tests or beta-hCG (could be molar)
What are positive signs of pregnancy?
o Objective signs assessed by an examiner that can be attributed ONLY to the presence of the fetus
Hearting fetal heart tones
Visualizing the fetus
Palpating fetal movements
o HCG doubling every 48 hours (could argue that this is still presumptive lol), won’t be an exam question
o Definitive signs that confirm pregnancy
What changes occur to the size of the uterus during pregnancy?
First trimester
o Uterine enlargement occurs due to
Increased vascularity and dilation of blood vessels
Hyperplasia
Hypertrophy
o Week 7 – size of an egg
o Week 10 – size of an orange
o Week 12 – size of a grapefruit
Second and third trimester
o Uterine enlargement occurs due to pressure of the growing fetus
What changes occur to the shape of the uterus during pregnancy?
- Preconception – upside-down pear shape
- Second trimester – spherical shape
- Late pregnancy – ovid shape
What changes occur to the contractility of the uterus during pregnancy (not labour)?
Prelabour contractions (Braxton Hicks)
o Intermittent, irregular, painless contractions that can be annoying
o Facilitate uterine blood flow and promote oxygen delivery to fetus
o Begins after 4th month until labour
o Does not increase in intensity or duration and does not cause cervical dilation (this would be labour)
Describe the uteroplacental blood flow.
What can increase/decrease this flow?
What can be used to measure this blood flow?
- More oxygen extracted from uterine blood during latter part of pregnancy
- Uterine blood flow increase by 10 fold, and about 1/6 of total blood volume is within the uterine vascular system
Factors that decrease uterine blood flow are
o Low arterial pressure
o Contractions of the uterus
o Supine position
Estrogen may stimulate an increase in uterine blood flow
Doppler can be use to measure uterine blood flow especially in pregnancies at risk due to conditions associated with decreased placental perfusion including
o Hypertension
o Intrauterine growth restriction
o Diabetes mellitus
o Multiple gestation
Ultrasound or fetal stethoscope may hear
o Uterine souffle or bruit
Rushing or blowing sound of maternal blood flowing through uterine arteries to placenta
Synchronous with maternal pulse
o Funic souffle
Fetal blood coursing through the umbilical cord
Synchronous with the fetal heart rate
o Fetal heartbeat
Describe the changes that occur to the cervix during pregnancy (not labour).
- Responsive to hormones
- Remains firm and closed to maintain pregnancy
- Nullipara – rounded cervix
- Previous vaginal birth – cervix is oval in the horizontal plan
AT WEEK 6
Goodell sign
* Softening of cervical tip
Velvety appearance
* Caused by proliferation at the external os (orifice)
Increased friability (tendency to break apart)
* Results in slight bleeding after vaginal exams or coitus
What is quickening?
When can this be felt?
What is this affected by?
Fluttering fetal movements
o Multiparous patient may feel it about week 14, nulliparous patient may not notice until 20 weeks
o Gradually increases in intensity and frequency
Starts as subtle flutter that is very delicate
At end of pregnancy you can see it outside of abdomen
o The week it starts may help date the gestation
Affected by
Maternal obesity
Multiples (twins, triplets etc)
Fetal position
What is Chadwicks sign and what is it caused by?
violet-bluish colour of vaginal mucosa and cervix
Caused by the increased vascularity
What is leukorrhea? Why does this occur?
Copious white/light grey mucoid discharge that smells faintly musty
Cervical response to estrogen and progesterone
The white is exfoliated vaginal epithelial cells caused by hyperplasia and is a normal finding
Describe the operculum
Aka the mucous plug
o Caused by leukorrhea mucous filling the endocervical canal
o Acts as a barrier against bacterial invasion
Describe the changes to the vaginal microbiome during pregnanccy?
o Decreased anaerobic bacteria but increases in Lactobacillus
o Decreases pH of vaginal secretions
o Changes prevent ascending bacterial infections
o May help establish gut microbiome of infant
Describe the changes to the external perineal structures during pregnancy.
They become enlarged due to
Increased vasculature
Hypertrophy of perineal body
Deposition of fat
What is the appearance of the labia majora during pregnancy?
Nullipara patients approximate and obscure the vaginal entrance
Separation and gape may occur due to
Previous childbirth
Perineal or vaginal injury
Describe the changes to breast size that occur during pregnancy
Early gestation may have the following due to increased estrogen/progesterone levels:
o Fullness
o Heaviness
o Heightened sensitivity (tingling to sharp pain)
Blood vessels – dilate and become more visible
Enlargement
o Occurs during 2nd and 3rd trimester
o Growth of mammary glands
Describe colostrum production that occurs during pregnancy
o Production begins by the end of the first trimester due to prolactin
o Secreted during the second trimester due to human placental lactogen
o Lactation inhibited until progesterone decline after birth
Describe striae gravidarm
o Also called stretch marks
o Generally occur on abdomen, thighs, and breasts
o May feel itchy
o Colour darkens as patients skin darkens
Describe the coarse nodularity that occurs to the breasts during pregnancy.
o Proliferation of the lactiferous ducts and lobule-alveolar tissue
o Result of high levels of luteal and placental hormones
Describe the changes to the areolas during pregnancy
o Primary areolae become more pigmented
o Secondary pinkish areolae develop beyond the primary areolae
o Nipples become more erect
Montgomery tubercles – small bumps around the primary areolae
Caused by hypertrophy of sebaceous glands embedded there
Help secrete lubricating and anti-infective substances to protect the nipples and areolas during breastfeeding
What occurs to the breast tissue during pregnancy that results in them becoming softer?
- Glandular tissue displaces connective tissues so breasts become softer and looser
What changes occur to the maternal heart size and position during pregnancy?
- Slight cardiac hypertrophy may occur but returns to normal size within 6 months of childbirth
o Elevated upward and rotated forward to the left
What maternal heart sound changes are noted during pregnancy?
o Apical pulse can shift up and out due to change in heart position
o Audible splitting of S1 and S2
o S 3
o Systolic and diastolic murmur (best heard over left sternal border)
o Generally returns to normal after birth
What maternal heart rate and rhythm changes occur during pregnancy?
Heart rate
o Begins to climb at 5 weeks and can reach a peak of 15-20 beats over normal
Cardiac rhythm
o Limited effects
o May cause
Sinus dysrhythmia
PACs or PVCs
o Close supervision should be made for those with pre-existing heart disease
Describe the blood volume changes that occur during pregnancy
- Increases by 1.2-1.5L above pregnancy level (40-50%)
o Rapidly rises early and peaks around 28-34 weeks before stabilizing
o Volumes are higher in multiple gestation
What is hemodilution that occurs during pregnancy?
o Also called physiological anemia
o RBCs only go up 17% though so lots of it is just plasma
o Hemoglobin and hematocrit both decrease
Peaks during second trimester
What changes occur to the WBC counts during pregnancy?
o Total increases during second trimester, peaking in third
o Mostly granulocytes
Why is the mother considered to be in a hypercoagulable state during pregnancy?
Why does this occur?
o Protective function to decrease chance of bleeding
o Increases risk of thrombosis especially after C-section
Caused by
Increase in clotting factors
Decrease in factors that inhibit coagulation
Depressed fibrinolytic activity
What changes occur to the maternal cardiac output during pregnancy?
Why does this occur?
- Increases 30-50%, with half occurring by 8 weeks
Results from
o Increased stroke volume
o Increased rate
o Increased tissue oxygen demands
What maternal BP changes may occur during pregnancy?
- Blood pressure remains stable or decreases slightly due to decreased systemic vascular resistance which is caused by
o Vasodilatory effects of progesterone, prostaglandins, and relaxin
o Uteroplacental vascular system holding a large percentage of blood volume
Systolic pressure
o Remains stable but can raise slightly during advanced pregnancy
Diastolic pressure
o Beings to decrease in first trimester until 28 weeks
o After 28 weeks, gradually returns to pre-pregnancy level at term
Define supine hypotension
o Also called vena cava syndrome
o Systolic drop >30 mmHg when laying supine
o Cause by compression of inferior vena cava by the baby
Describe the pulmonary changes that occur to the mother during pregnancy
Maternal oxygen consumption increases by 20-40% during pregnancy
Diaphragm pushed up as much as 4 cm by enlarging uterus
o Less able to participate in breathing
o Chest breathing becomes more predominant
Lower ribs flare out and rib cage ligaments relax increasing chest expansion
Upper respiratory tract becomes more vascular leading to
o Increased nasal and sinus stuffiness
o Epistaxis
o Changes in the voice
o Marked inflammatory response to even a mild upper respiratory tract infection
o Swelling of tympanic membrane and eustachian tube leading to
Impaired hearing
Earaches
Sense of fullness in the ear
Tidal volume increases by 40%
Respiratory alkalosis occurs facilitating the transport of CO2
Describe bladder symptoms that occur during pregnancy
Bladder symptoms early in pregnancy and again near term
o Bladder irritability
o Nocturia
o Urinary frequency and urgency (without dysuria)
What changes occur to the ureters and what can this cause?
Changes
Ureter walls undergo hyperplasia, hypertrophy, and muscle tone relaxation
Ureters above the renal brim and the renal pelvis dilate
Ureters elongate, become tortuous, and form single or double curves
Results
Larger volume of urine is held in renal pelvis and ureters and urine flow slows
Consequences
Urinary stasis or stagnation can result in
* Lag between urine formation and reaching the bladder affecting clearance test results
* Increased risk of UTI
o Higher sugar content and higher pH level don’t help this risk
What is the result of the bladder being pushed upward into the abdomen during the second trimester by the uterus?
Results in urethra that lengthens in response and can cause
o Hyperemia of bladder and urethra due to pelvic congestion
o Mucosa off bladder is easily traumatized resulting in bleeding
o Bladder tone decreases increasing capacity
o Bladder compressed by the uterus resulting in urge to void even if its mostly empty
What is the effect of pregnancy on renal function? What can help or hinder renal function?
GFR increases in early pregnancy resulting in
o Increased creatinine clearance
o Decreased serum creatinine, BUN, and uric acid levels
Most efficient in side lying
Supine position results in vena cava and aorta compression and kidney blood flow deceases
How does the body maintain the isotonic state for the additional fluid volumes associated with pregnancy?
Tubular resorption of sodium increases
What is physiological edema of pregnancy?
o Edema that occurs in the lower legs during later pregnancy
o Does not require treatment
o When patient is side lying, the pooled fluid will re-enter circulation
Describe glucosuria during pregnancy and what should be considered if it is noted
o May occur at varying times due to impaired glucose resorption
o If noted, possibility of DM or gestational diabetes should be considered
Describe proteinuria during pregnancy and what should be considered if it is noted
o Increased excretion of protein and albumin after 20 weeks
Due to increased GFR and impaired proximal tubular function
o There are abnormal levels, but the amount isn’t an indication of severity
o If patient also has HTN, careful evaluation should occur
What parts of the body may experience darkening after about 16 weeks gestation?
nipples, areolae, axillae, and vulva
What is facial melasma?
o Blotchy, brownish hyperpigmentation of skin over cheeks, nose, forehead
o Begins about week 6 and darkens gradually until term but usually fades after birth
o More likely in those with dark complexions
What is linea nigra?
o Pigmented line extending from symphysis pubis to the top of the fundus
o With the first baby, it grows as the baby grows, subsequent pregnancies it just appears
Describe angiomatas
o Also called vascular spiders
o Tiny, star-shaped, lightly raised, pulsating end-arterioles
o Appear on neck, thorax, face, and arms during months 2-5 and usually disappear a few months after birth
What is palmar erythema?
o Pinkish-red diffusely mottled or well-defined blotches over palmar surfaces that occurs during pregnancy
Describe pruritis gravidarum
o Mild pruritic over abdomen that usually resolves after birth
o Topical steroids and emollients may help with itching
Describe polymorphic eruption of pregnancy (PEP)
o Also called pruritic urticarial papules and plaques of pregnancy (PUPPP)
o Very itchy red bumps that appear over the abdomen and while it can cause significant discomfort, it is not associated with adverse outcomes for mom or baby
o Occurs late in pregnancy and resolves after birth
Less common but associated with
Increased weight gain during pregnancy
Multiple gestations
Hypertension
Induction of labour
Usually treated with oral antihistamines and topical antipruritic and corticosteroid creams; severe cases may need oral steroids
Describe acne during pregnancy
o Can worsen during pregnancy (or be a new onset)
o Accutane is a teratogen, so should be avoided
Describe perspiration during pregnancy
Increases due to
Increased blood supply to the skin
Increased metabolic rate
Describe hirsutism that may occur during pregnancy
o Excessive growth of hair or growth in unusual places
o Fine hair likely to disappear after pregnancy, but coarse hair does not usually
Describe hair loss during pregnancy
o Growth may be accelerated
o Scalp hair loss slows during pregnancy
o Increased hair loss may be noted after birth
Describe nail changes during pregnancy
o Growth may be accelerated
o Thinning and softening of the nails may be noted
What are musculoskeletal adaptations during pregnancy?
- Center of gravity shifts forward
- Lordosis develops
- Lower back pain occurs due to low spine stress
- Pelvic relaxation
- Abdominal wall stretches, losing muscle tone
Why does lordosis during pregnancy cause
o Accentuated by large breasts and stoop-shouldered stance
o Compensatory exaggerated anterior flexion of the head develops to help maintain balance
Describe pelvic relaxation during pregnancy
o Permits enlargement of pelvis to facilitate birth
o Considerable separation of symphysis pubis and instability of SI joints causes pain and difficulty walking
o Waddling gate
Describe diastasis recti abdominis
Rectus abdominis that separates in the third trimester
May persist even after birth as muscle regains tone
Describe neurological symptoms that may be experienced during pregnancy
o Sensory changes in lower limbs due to compression of pelvic nerves and blood vessels
o Pain caused by lordosis pulling or compressing nerves
o Carpal tunnel syndrome
o Acroesthesia (loss of sensation in the hands)
o Tension headaches
o Lightheadedness or syncope
o Muscle cramps or tetany may be caused by hypocalcemia
o Corneal thickening and decreased intraocular pressure occur during pregnancy and resolves shortly after birth
Describe morning sickness
Up to 80% experience it
Usually subsides at the end of the first trimester
Ranges from mild distaste for some foods to sever vomiting
Describe hyperemesis gravidarum
Occurs in 1% of pregnancies
Persistent vomiting leading to a weight loss of >5%
Associated with electrolyte imbalance and ketonuria
Intervention likely required
Describe the changes that may happen to the mouth during pregnancy
Gums
o Hyperemia, spongy, and swollen
o Bleed easier
Epulis
o Also called gingival granuloma gravidarum
o Red, raised nodule on the gums that bleeds easily
o May develop in third month and enlarge throughout pregnancy
o Avoid trauma to area
o Usually regresses after birth
Increased risk for gingivitis and periodontitis
o Periodontitis associated with poor pregnancy outcomes such as
Preterm birth
Low birth weight baby
Describe the changes that happen to the esophagus and stomach during pregnancy
Decreased tone and motility of smooth muscles, causing
o Esophageal regurgitation
o Slower stomach emptying
o Reverse peristalsis
Pyrosis
o Heartburn or acid indigestion
o May be as early as first trimester and intensify throughout pregnancy
Hiatal hernia
o Increased risk due to upward displacement caused by uterus
o More common in multiparas and older or obese patients
Why might constipation occur during pregnancy?
Smooth muscle relaxation and reduced peristalsis
Change in food intake and type of foods
Lack of fluids
Iron supplements
Decreased activity
Abdominal distension of the uterus
Displacement and compression of intestines by gravid uterus
Describe the changes that can happen to the intestines/anus during pregnancy
Iron absorption in small intestines increases
Microbiome changes
o May protect the fetus and contribute to establishing the microbiome of the newborn
Constipation
Hemorrhoids
o Swollen veins in the lower rectum (internal) or on the anus (external)
o Common to develop in the third trimester and often resolve after birth
o Can evert or bleeding during straining at stool from constipation
Describe changes that happen to the gall bladder during pregnancy
- Often distended due to decreased muscle tone
- Slower emptying times results in thickening bile and possible stones
Describe the changes to the liver during pregnancy
Hemodilution results in serum albumin and total protein levels to decrease
ALP increases up to 4 times normal but other LFTs remain normal
Intrahepatic cholestasis
o Retention and accumulation of bile in the liver
o May occur late in pregnancy due to placental steroids
o May result in severe itching and possibly jaundice
What are common causes of abdominal discomfort during pregnancy?
o Pelvic heaviness or pressure
o Round ligament tension
o Flatulence
o Distension
o Bowel cramping
o Uterine contractions
Be alert because it may be caused by
o Bowel obstruction
o Inflammatory process
Why is appendicitis difficult to diagnose during pregnancy?
Because the appendix is displaced
Describe the production and role of hCG during pregnancy
- Produced by trophoblast tissue and eventually chorionic villi
- Supports function of corpus luteum
- Measuring levels can help in
o Identifying a normal pregnancy
o Pathologic pregnancy or pregnancy complications
o Following an aborted pregnancy - Levels vary widely between women
o Exponentially rise in first trimester and peaks at week 10
Describe the production and role of progesterone during pregnancy
- Produced initially by corpus luteum and then by placenta
- Inhibits FSH and LH
- Helps establish placenta
- Stimulates growth of blood vessels that supply the womb
- Inhibits contraction of the uterus so it can grow with baby
- Strengthens pelvic wall muscles for labour
- Causes fat deposit in subQ tissues of maternal abdomen, back, and upper thighs
- Decreases ability to utilize insulin
Describe the production and role of estrogen during pregnancy
- Produced initially by corpus luteum and then by placenta
- Inhibits FSH and LH
- Helps uterus grow and maintain its lining
- Helps fetal organ develop
- Activates and regulates production of other hormones
- Works with progesterone to stimulate breast growth and mild duct development
- Causes fat deposit in subQ tissues of maternal abdomen, back, and upper thighs
- Increases retention of sodium and water
Describe the production and role of prolactin during pregnancy
- Produced by anterior pituitary gland
- Main hormone needed to produce milk
- Contributes to enlargement of the mammary glands and prepares them for milk production
- Inhibits lactation during pregnancy
Describe the production and role of relaxin during pregnancy
- Produced initially by corpus luteum and then by placenta
- Inhibits uterus contraction to prevent premature birth
- Vasodilates to increase blood flow to placenta and kidneys
- Relaxes joints of pelvis
- Softens and lengthens the cervix during birth
Describe the production and role of oxytocin during pregnancy
- Produced by posterior pituitary gland
- Levels rise at start of labour stimulating uterine contractions
- Triggers production of prostaglandins further increasing contractions
- Can be used to induce labour
- Stimulates milk ejection from breasts
Describe the production and role of human placental lactogen during pregnancy
- Previously called chorionic somatomammotropin
- Produced by placenta
- Acts as a growth hormone
- Contributes to breast development
- Decreases maternal metabolism of glucose
- Increases the amount of fatty acids for metabolic needs
What are some psychological adaptations of the mother during pregnancy?
Accepting the pregnancy
Identifying with the mother role
Reordering personal relationships
Establishing a relationship with the fetus
Preparing for the birth
What are the 3 stages of a mother developing a relationship with the fetus
1 - I am pregnant
2 - I’m going to have a baby
3 - I’m going to be a mother
What psychological adaptations happen to the non-pregnant partner?
Accepting the pregnancy
Identifying with the father role
Reordering personal relationships
Establishing a relationship with the fetus
Preparing for the birth
What are the 3 phases for men to accepting the prengancy?
1 - Announcement
2 - Moratorium (adjusts to reality, probably talks to their own dad)
3 - Focusing phase (usually last trimester and begins to actively become involved)
What are the 3 stages of prenatal development and what are the timelines for them?
Germinal phase - conception to end of week 2 (embryology count)
Embryonic phase - week 3 to the end of week 8 (embryology count)
Fetal development - week 9 to end of pregnancy (embryology count)
Describe the germinal phase
- Conception until the end of week 2 (embryology counts)
- Fertilized ovum divides and burrows into the uterus
- Not susceptible to teratogenesis
- Death of the embryo and spontaneous abortion are common
Which phase is critical for differentiation? What is it most susceptible to during this phase?
Embryonic phase
Embryo is most susceptible to damage from external sources including
o Teratogens (i.e. alcohol, medications)
o Infections (i.e. rubella, cytomegalovirus)
o Radiation
o Nutritional deficiencies
What is the production and development of the organs in the developing fetus called? When does this occur?
Organogenesis
Occurs during the embryonic phase begins in week 3 and continues until the end of week 8 (embryology counts)
What are some of the major congenital anomalies that may occur during the embryonic phase?
o Neural tube defects
o Heart defects
o Limb abnormalities including missing parts of limbs/extremities
o Cleft lip or cleft palate
o Deafness
o Ocular defects
o Enamel hypoplasia (undeveloped tooth enamel)
o Masculinization of female genitalia
Describe the embryonic phase
- Weeks 3 to completion of week 8 (embryology counts)
- Critical period of differentiation
- By the end of embryo phase, it is starting to resemble a human being
- Embryo is most susceptible to damage from external sources
Organogenesis
o Begins on day 17-19 until the end of week 8
o Starts with formation of the neural plate and continues until the end of the embryonic phase
o Beginning development of the
Neural tube forms which then becomes the spinal cord
Brain
GI tract
Arm and leg buds appear and grow out from the body as they develop
o Heart development
Complete at the end of embryonic phase
Fetal heart rate may
What damage is the most likely to occur during fetal phase of development?
- Functional defects and minor anomalies may occur
Describe the fetal development that occurs from weeks 9-12 (embryonic counts)
o Sexual differentiation continues
o Fetal heartbeat can be heard by the end of week 12
o Heartbeat is discernible by ultrasound
o First movements begin at 12 weeks
o Kidneys begin to produce urine
Describe the fetal development about week 16 (embryonic counts)
o Meconium in bowel
o Musculoskeletal system has matured, most bones are distinct
o Fetus makes active movement
o Weight quadruples
o Fetal heartrate is discernible with Doppler
o Baby’s sex can be determined by ultrasound
Describe the fetal development about week 20 (embryonic counts)
o Fetal movement (quickening) detected by mother
o Enamel on teeth is depositing
o Bones ossifying
o Brain grossly formed, spinal cord myelination begins
o Vernix caseosa, a white, greasy film, covers the fetus
o Eyebrows, eyelashes, and head hear develop
Describe the fetal development about week 24 (embryonic counts)
o Respiratory movements begin and alveoli are forming
o Lungs begin to produce surfactant
o Can hear
o Eyelashes and eyebrows well formed
o Fetus has a hand grasp and startle reflex
o Skin is red and translucent
Describe the fetal development about week 28 (embryonic counts)
o Fetus about 15 inches or 28.1 cm long
o Rapid brain development
o Fetus can breathe, swallow, and regulate temperature
o Eyelids reopen so they can now open and close
o Fetus usually assumes head-down position (cephalic presentation)
o Nervous system controls some functions
o Fingerprints are set
o Blood formation shifts from spleen to bone marrow
Describe the fetal development about week 32 (embryonic counts)
o Body fat rapidly increases
o Lungs developed but immature
o Rhythmic breathing movements
o Fetus stores iron, calcium, and phosphorus
o Increased CNS control over body functions
Describe the fetal development about week 38 (embryonic counts)
o Fetus is considered full term and fills the uterus
o Maternal antibodies are transferred to the baby
o Testes are in scrotum of male fetus
o Small breast buds are present on both sexes
o Lanugo begins to disappear
o Body fat continues to increase
o Fingernails reach the end of the fingertips
Describe the main functions of the placenta
Circulation
o Exchange metabolic and gaseous products between fetal and maternal circulatory systems
Hormone production
o Production of hormones necessary for fetal development and continuation of pregnancy
Describe the development of the placenta
Trophoblast
o Precursory cells of the placenta
o First appear 4 days after fertilization
o Initially appear as outer layer of blastocyst
Upon implantation of the blastocyst into the maternal endometrium, trophoblasts continue to differentiate forming the inner and outer layers of the placenta (eventually the chorion and amnion)
What vessels are in the umbilical cord?
2 arteries and 1 vein
What is the umbilical cord formed from?
Amnion of the placenta
What is Wharton’s Jelly? What is it’s function?
o Thick gelatinous substances that surround the vessels in the umbilical cord
o Prevents compression
What is gravidity? What is nulligravida, primigravida, and multigravida?
pregnancy, or number or pregnancies including current one
o Nulligravida – A person who is not and has not been pregnant
o Primigravida – A person who is pregnant for the first time
o Multigravida – A person who has had 2 or more pregnancies
What is parity? What is nullipara, primipara, and multipara?
Number of pregnancies that have surpassed 20 weeks gestation. Not affected by number of fetuses or if they are born alive or stillborn
o Nullipara – A person who has not had a pregnancy > 20 weeks before
o Primipara – One pregnancy that is > 20 weeks
o Multipara – A person who has had 2 or more pregnancies > 20 weeks
Describe viability
Capacity to live outside the uterus, generally 22-25 weeks is the threshold
What is a term pregnancy? What are the various terms associated with being around term and what gestation do they imply?
Term – A pregnancy between 37 weeks and 40 weeks + 6 days
o Preterm – Pregnancy between 20 weeks and 36 weeks + 6 days
o Late preterm – Pregnancy between 34 weeks and 36 weeks + 6 days
o Early term – Pregnancy between 37 weeks and 38 weeks + 6 days
o Full term – Pregnancy between 39 weeks and 40 weeks + 6 days
o Late term – Pregnancy in week 41
o Post term – Pregnancy after 42 weeks
During the antenatal assessment, what information should be covered in the current pregnancy history?
Review of symptoms and coping skills
Estimated date of birth
Environmental risks
What are the various methods used to determine the estimated date of birth?
Naegele’s rule
Subtract 3 months, add 7 days to LMP
This is what the wheel is based on
Just an estimate and could change with US
Best practice is dated by ultrasound
Done at 18-22 weeks in anatomy scan
Can confirm EDB +/- 2 days
During the antenatal assessment, what information should be covered in the childbearing and female reproductive system history?
Menstrual history
o Age at first menarche
o Date of LMP
Contraceptive history
Infertility or gynecological conditions
STI history
o HIV, syphilis, gonorrhea, chlamydia – these are teratogenic
Sexual history
Last Papanicolaou (Pap) test and any results
Past pregnancies (GTPAL)
o Previous losses or multiple losses
o Complications
o Trauma from previous pregnancies/birth
During the antenatal assessment, what information should be covered in the past medical/surgical history?
o Physical or surgical procedures that can affect, or be affected by, pregnancy
o Allergies, medication use, and immunization status
o Previous or chronic medical conditions
During the antenatal assessment, what information should be covered in the nutritional history?
o BMI
o Nutritional advice should consider cultural influence
o Obese patients should be aware of complications for themselves and fetus
o History of bariatric surgery are at a nutritional risk
o Maternal weight gain and fetal growth should be monitored
Special diet practices
Food allergies
Eating behaviours
Pica
During the antenatal assessment, what information should be covered in the socioeconomic history?
- History of drug use and herbal preparation use
- Family history
- Social, experiential, and occupational history (like supports, perceptions, or activities)
- Physical, sexual abuse and intimate partner violence
Describe the GTPAL acronym for obstetrical history
G – Gravidity
o Number of all pregnancies including this one
T – Term births
o Births at >37 weeks gestation
P – Preterm births
o Births between 20 and 36 weeks + 6 days
A – Abortions and miscarriages
o Any abortions or spontaneous abortion before 20 weeks gestation
L – Living children
o Number of children currently alive the woman gave birth to
What does it mean when someone is G2P0?
Gravida (number of pregnancies including this one) is 2
Para (number of pregnancies >20 weeks) is 0
Older style, less informative than GTPAL
What type of lab tests should be done in the antenatal visits?
ABO and Rh factor
CBC, hemoglobin, WBC
Rubella and varicella
STIs (blood and vaginal/rectal smear)
1-hour glucose tolerance test
What is Rh incompatibility?
o Occurs when mothers blood type is Rh negative and her fetus’ blood type is Rh positive
o Some of fetus’s blood passes into the mother’s blood stream and her body creates antibodies in response (alloimmunization)
o First pregnancy is usually not affected as the exchange usually happens at the time of birth
o In the next Rh-positive pregnancy, maternal antibodies attack fetal red blood cells resulting in lysis
o Risk and severity of sensitization response increases with each subsequent pregnancy involving an Rh+ baby
How is Rh incompatibility treated?
o Prevention is the best treatment
o Prophylactic RhIG is administered to Rh-negative (D-negative) pregnant patient
Destroys any fetal red blood cells in the maternal circulatory system before the immune system does so the mother does not produce antibodies
A dose of 300 mcg RhIG given at 26-30 weeks if mother is Rh negative and unsensitized
o If baby is Rh positive, dose is repeated within 72 hours after birth
o If mom refuses the shot, miscarriage in further pregnancies is common and mom should be aware as part of full consent
When is Group B streptococcus screened for in a pregnant mother?
35-37 weeks gestation
Describe the increased needs for calories for each trimester
First trimester
o Same as nonpregnant
Second trimester
o Nonpregnant needs and an additional 340 kcal (calories)
Third trimester
o Nonpregnant needs and an additional 452 kcal
What risks are underweight pregnant mothers associated with?
Preterm birth
Small for gestational age baby
Spontaneous abortion
Intrauterine growth restriction (IUGR)
What risks are overweight pregnant mothers associated with?
- Intrauterine growth restriction (IUGR)
- Macrosomia
o Much larger than average baby
o Difficult to deliver due to fetopelvic disproportion
Capacity for woman’s pelvis is insufficient for the safe vaginal delivery of the baby - Operative vaginal birth (i.e. forceps)
- Emergency Caesarean birth
- Postpartum hemorrhage
- Wound, genital tract, or urinary tract infection
- Birth trauma
- Late fetal death
- Pre-eclampsia
- Gestational diabetes
Describe pica during pregnancy including examples, causes, and results
Classified as an eating disorder and may be caused by delusions
o We may need to look into their mental health
Consumption of nonfood substances or excessive amounts of foodstuffs low in nutritional value, can be toxic
Associated with mineral deficiency (low iron)
May include
o Excessive ice chewing
o Eating backing soda, laundry detergent etc.
May cause
o Nutritional food displaced from diet
o Interference with absorption
May result in nutritional deficits in mom and baby
What are ways to manage nausea/vomiting during pregnancy?
- Consider low-iron prenatal vitamins
- Small frequent meals
- Try not to mix food and drinks
- Do not skip meals
- Eat pregnancy-safe foods that are appealing
o Try salty and tart foods - Aoid strong odours
- Avoid sudden movements
- Get fresh air, use an exhaust fan when cooking
- Eat room temp or cool foods that have little to no smell
- Try candies, gummies or lozenges for metallic taste in the mouth
- Avoid brushing teeth immediately after eating
How can pregnant women avoid UTIs?
o Proper hand hygiene and wiping pattern
o Soft, absorbent toilet paper
o Avoid bubble bath or bath oils
o Cotton underwear
o Adequate fluid intake
o Not holding urine
o Cranberry capsules
What exercises during pregnancy can help strengthen the pelvic floor?
Kegel
What is fundal height and what can it help us determine?
- Distance from pubic bone to top of the uterus
- Helps determine gestational age and fetus position
What are the expected fundal heights during pregnancy?
- After week 20, fundal height in cm is approximately the same as the number of weeks of gestation, +/- 2 weeks (mother’s bladder should be empty)
o Week 12-14 – fundus palpable above the symphysis pubis
o Week 20-22 – fundus at umbilicus
o Week 36 – fundus at xiphoid process
Describe lightening and when this occurs.
slight decrease in fundal height
o Result of fetus descending into pelvis
o Usually occurs after 36 weeks, provider may order tests to rule out other causes
o Nullipara – occurs anytime in 4 weeks before labour onset
o Multipara – occurs at start of labour
How is fundal height measured?
o Use a disposable paper tape
o Palpate pubis symphysis and place the 0 there
o Measure to the top of the uterus and document results
What can it mean if the fundal height is measuring behind gestational age?
- Petite mother
- Strong maternal abdominal muscles
- Oligohydramnios (not enough amniotic fluid)
- Fetus has dropped into the pelvis
- Intrauterine growth restrictions (IUGR)
What can it mean if the fundal height is measuring ahead of gestational age?
- Incorrect due date
- Uterine fibroids
- BMI > 25
- Carrying multiples
- Polyhydramnios (excessive amniotic fluid)
- Breech positioning
- Fetal macrosomia (large baby, may be caused by gestational diabetes)
What is Leopold’s Maneuver? What are the basic steps?
Systematic way of palpating the maternal abdomen to determine
o Number of fetuses
o Fetal presentation, fetal lie, and fetal attitude
o Degree of descent of the presenting part into the pelvis
o Point of maximal intensity of the fetal heart rate on the mothers abdomen
1 - determine the fetal part in the fundus
2 - determine where the fetal back is located
3 - determine presenting part over inlet to pelvis
4 - Determine if head is flexed/extended and engaged/free-floating
Describe fetal presentation and what the possible answers are
The presenting part
Cephalic - head first
Breech - butt or feet first
Shoulder - rare but shoulder first
Describe fetal attitude and how may this be described?
General flexion
Describes the position of specific parts of the fetus’s body
Optimal attitude allows for the smallest biparietal diameter to enter the pelvic inlet
o Chin tucked to the chest
o Arms and legs drawn into the center of the chest
If the fetal head is abnormally flexed or extended the presenting head diameter may exceed the maternal pelvis leading to prolonged labour and interventions
May be described as
o Occiput/Vertex
o Sinciput/Military
o Brow/face
What are some risk factors for polyhydramnios?
- Poorly controlled diabetes mellitus
- Fetal-maternal hemorrhage
- Fetal congenital anomalies including
o Gi obstruction
o CNS abnormalities - Genetic disorders
- Twin-twin transfusion syndrome
What are some risk factors for intrauterine growth restriction?
Maternal Factors
* Hypertensive disorders
* Pregestational diabetes
* Cyanotic heart disease
* Autoimmune disease
* Restrictive pulmonary disease
* Multifetal gestation
* Malabsorption disease/malnutrition
* Living at high altitude
* Tobacco or substance use
Fetal Factors
* Genetic disorders
* Teratogenic exposure
* Fetal infection
What are some risk factors for oligohydramnios?
- Renal agenesis (Potter syndrome)
- Premature rupture of membranes
- Prolonged pregnancy
- Uteroplacental insufficiency
- Severe intrauterine growth-restriction (IUGR)
- Maternal hypertensive disorders
- Maternal dehydration/hypovolemia
What are some risk factors for fetal chromosomal abnormalities?
- Advanced maternal age
- Paternal chromosomal rearrangements
- Previous pregnancy with autosomal trisomy
- Abnormal ultrasound findings during the current pregnancy including
o Fetal structural anomalies
o IUGR
o Amniotic fluid volume abnormalities - Increased risk as calculated from noninvasive screening results including
o Nuchal translucency
o Maternal serum analytes
What is the term for pregnancy?
Gravidity
What is the term for the number of pregnancies in which the fetus or fetuses have reached 20 weeks of gestation, not the number of fetuses born. The numeric designation is not affected by whether the fetus is born alive or stillborn
Parity
What is the term for a woman who is pregnant?
Gravida
What is the term for a woman who has never been pregnant?
Nulligravida
What is the term for a woman who has not completed a pregnancy with a fetus or fetuses beyond 20 weeks of gestation?
Nullipara
What is the term for a woman who is pregnant for the first time?
Primigravida
What is the term for a woman who has completed one pregnancy with a feus/fetuses who have reached 20 weeks of gestation or more?
Primipara
What is the term for a woman who has had 2 or more pregnancies?
Multigravida
What is the term for a woman who has completed 2 or more pregnancies to 20 weeks of gestation or more?
Multipara
What is the term for the capacity to live outside the uterus?
Viability
What is generally considered the threshold for viability?
Between 22-25 weeks gestation
What is the term for a pregnancy that has reached 20 weeks of gestation but ends before completion of 36 weeks gestation?
Preterm
What is the term for a pregnancy from 39+0 weeks to 40+6 weeks gestation?
Full term
What is the term for a pregnancy that goes beyond 40+0 weeks gestation?
Postterm
What is the term for the biological marker on which pregnancy tests are based? Its presence in the urine/serum results in a positive pregnancy test result.
Human chorionic gonadotropin
What is the term for pregnancy-related changes felt by the pregnant patient?
Presumptive changes
What is the term for pregnancy-related changes that can be observed by an examiner?
Probable changes
What is the term for objective signs that can be attributed only to the presence of the fetus?
Positive changes
How much folic acid should be taken by the mother and when?
400 mcg 3 months before until 6 months post partum
What is the term for irregular, painless uterine contractions that can be felt through the abdominal wall soon after the fourth month of pregnancy?
Braxton Hicks
What is the term for fetal movements felt first by the pregnant patient as early as 16-20 weeks gestation?
Quickening
What is the term for a change in blood pressure as a result of compression of abdominal blood vessels and decrease in cardiac output when a pregnant patient lies down on their back?
Supine hypotensive syndrome
What is the term for nonfood cravings for substances such as ice, clay, and laundry starch?
Pica
The first stage of labour begins with the_________ and ends when the cervix is ________ cm dilated.
- onset of regular contractions
- 10
What are signs a pregnant patient may experience (prior to regular contractions) that are indicative of approaching labour?
Lightening
Lower body ache
Bloody show
Spontaneous rupture of membranes
Cervical changes (early dilation and effacement as well as ripening where the cervix softens)
Surge of energy (nesting)
During the active phase of the first stage of labour, the cervix dilates from ____ to ____ cm
4-10
What is the normal fetal heart rate?
110-160 bpm
As labour progresses, what should happen to the frequency, duration, and intensity of contractions?
All increase
What is the resting tone of the uterus? What is considered normal? Why is this?
The tone of the uterus between contractions
Should be soft to allow for improved blood flow to the fetus
If it is hard on palpation between contractions, the baby may not be getting adequate oxygen
What is the relationship of the presenting part to an imaginary line in the maternal pelvis? What is the landmark used for this line?
Fetal station
Ischial spines
________is the softening, thinning, and shortening of the cervical canal and may be expressed as a %
More often, the cervix is described as thick, thinning, or thin or the cervix is described as length in ____
Effacement
cm
What is the most optimal fetal position for a safe vaginal delivery?
right occipital anterior
The second stage of labour is the stage in which the ________. It begins with full ______ and complete or 100% _______ of the cervix. It ends with the __________.
Baby is born
Dilation
Effacement
Birth off the baby
What are the signs that the second stage of labour is begining?
Ferguson’s reflex (urge to push or defecate)
Shaking extremities
Sudden appearance of sweat on the upper lip
Episode of vomiting
Increased bloody show___
Increased restlessness
Involuntary bearing down
The third stage of labour lasts from the _________ until the _________. Detachment of the placenta from the wall of the uterus, or _________, is indicated by a ___________, change to a _______ shape, a sudden _____________ from the introitus, and apparent lengthening of the _______________.
Birth of the baby
Delivery of placenta
Separation
Firmly contracting uterus
Globe
Rush of blood
Umbilical cord
The first 1-4 hours after birth is considered the ______
4th stage of labour
________ medications are the classification of medications that stimulate contraction of the uterine smooth muscle
Oxytocic
___________ is the failure of the uterine muscle to contract firmly. It is the most frequent cause of ___________ following childbirth.
uterine atony
postpartum hemorrhage
A _________ is the perineal treatment that involves sitting in warm water for approximately 20 minutes to soothe and cleanse the site and to increase blood flow, thereby enhancing healing
Sitz bath
__________are menstrual-like cramps experienced by many women as the uterus contracts after childbirth and are more apparent while breastfeeding
Afterpains
Complaint of pain in calf muscles is associated with the presence of a ________ or __________. Additional signs include ________, __________, or ________ in the suspected leg
Thrombus or thrombophlebitis
Heat, tenderness, redness
_________exercises assist women to maintain perineal tone during pregnancy and help regain perineal muscle tone postpartum. Muscle tone is often lost when pelvic tissues are stretched and torn during pregnancy and birth
Kegel
_________ is an immunoglobulin product that is administered to Rh-negative, antibody (Coombs)-negative women who delivered an Rh-positive newborn. it is administered by ________, within _________after birth
Rhogam
IM injection
72 hours
What is the average FHR during a 10-minute tracing segment that excludes accelerations, decelerations, and periods of marked variability?
Baseline fetal heart rate
What is the term for an amplitude range of FHR fluctuations that is undetectable?
Absent variability
What is the term for an amplitude range detectable by the unaided eye, but is <5 bpm?
Minimal variabiliity
What is the term for persistent (>10 min) baseline FHR <110 bpm?
bradycardia
What is the term for visually apparent decrease in FHR of 15 bpm or more below the baseline, which lasts between 2 and 10 minutes?
prolonged deceleration
What is the term for changes from baseline patterns in FHR that occur with uterine contractions?
periodic changes
What is the term for persistent (>10 min) baseline FHR > 160 pbm?
tachycardia
What is the term for fluctuations in the baseline FHR that are irregular in amplitude and frequency and are visually quantified as the amplitude of the peak to trough in bpm?
variability
What is the term for visually apparent gradual decrease in and return to baseline FHR in response to transient fetal head compression during a uterine contraction? Is this a good, bad, or ugly sign?
early deceleration
Considered normal and benign
What is the term for visually apparent gradual decrease in and return to baseline FHR in response to uteroplacental insufficiency resulting in a transient disruption of oxygen transfer to the fetus? When does this occur?
late deceleration
Lowest point occurs after the peak of the contraction and baseline rate is not usually regained until the uterine contraction is over
What is the term for visually abrupt decrease in FHR below baseline of 15 beats or more, lasting 15 seconds and returning to the baseline in less than 2 minutes that occurs any time during the contraction? What is this a sign of?
Variable deceleration
Result of umbilical cord compression
What is the term for visually abrupt increase in the FHR of 15 bpm or greater above the baseline, lasting 15 seconds or more with a return to baseline in less than 2 minutes?
Acceleration
What is the term for changes from baseline patterns in FHR that are not associated with uterine contractions?
episodic changes
Describe fetal lie. How may lie be described?
Relation of the long axis (spine) of the fetus to the long axis (spine) of the mother
Longitudinal
o Ideal lie
o Spines line up vertically with fetal head in down in the birth canal
Transverse
o Fetus is sideways or horizontal across the uterus
o Not compatible with a vaginal birth
Oblique
o Usually converts to longitudinal or transverse lie during labour
How do we describe fetal position? What are the options for each part?
We use a 3 letter abbreviation used to describe the fetal position
First letter denotes the side of the mothers pelvis the presenting part is located in
o R – right
o L – left
Second letter is the presenting part of the fetus
o O – occiput
o S – sacrum
o M – mentum
o Sc – scapula
Third letter represents the location of the presenting part in relation to the maternal pelvis
o A – anterior
o P – posterior
o T – transverse
What is the most important indicator of an uncomplicated vaginal birth?
Fetal position as some presentations have different diameters which may prevent natural labour
ROA is the most optimal
When can a doppler detect a fetal heartbeat?
12 weeks gestation
How is the FHR heart best? How do we find it?
Point of maximal intensity (PMI) is heard through the fetal back…use Leopolds to figure out where that is?
What is the PMI and what happens to it as the fetus descends into the pelvis during labour?
Point of maximal intensity (where we heart the FHR best)
Continues to be heard lower on the abdomen and moves closer to the midline
Where is the PMI in a breach baby?
Above the umbilicus
What is the most significant intrapartum sign of fetal compromise?
Minimal or absent FHR
What is considered fetal bradycardia? What can cause it?
Rate < 110 bpm although 110-119 is usually not a sign of compromise in the absence of other concerning symptoms
Etiology
o Heart block
o Occiput posterior or transverse position
o Serious fetal compromise
What is considered fetal tachycardia? What can cause it?
Rate > 160 bpm
o Good variability of tachycardia is not a sign of fetal distress
Etiology
o Maternal fever
o Fetal hypoxia
o Fetal anemia
o Amnionitis
o Fetal tachyarrhythmia
Usually >200 with abrupt onset and little to no variability
o SVT (200-400)
o Fetal heart failure
o Drugs
Beta sympathomimetics
Vistaril
Phenothiazines
o Rebound
Transient tachycardia following a deceleration accompanied by decreased variability
How should fetal movements be counted and how many movements would be considered normal?
Should be counted with mother in a reclined position
Should feel at least 6 distinctive fetal movements in 2 hours
If mom is walking, she may feel rebounding and not actual movements
Babies can sleep, if this is suspected, have mom get up and move around, drink some juice, etc. to wake the baby up and then sit down to try again
What can affect fetal movement counting?
If mom is walking, she may feel rebounding and not actual movements
Babies can sleep, if this is suspected, have mom get up and move around, drink some juice, etc. to wake the baby up and then sit down to try again
What are risk factors for decreased fetal movemnts?
Decreased placental perfusion
Fetal acidemia
What is a non-stress test? What does it measure? When might it be done?
A non invasive test that is done during the 3rd trimester
Measures FHR in response to fetal movement
Indicated when there has been decreased fetal movement, advanced maternal age, gestational HTN, or post maturity
What are the normal results of an NST?
Baseline 110-160 bpm
Accelerations
o 2 accelerations with an increase of ≥15 bpm, lasting at least 15 second
o Indicates fetal movement
Variability
o 6-25 bpm (moderate)
o Absent or minimal is ≤ 5 bpm for < 40 min
Decelerations
o None or occasional variable <30 seconds
What is an ultrasound and what does it allow us to do?
- High frequency sound waves deflect off tissues showing structures of various densities
- Visualizes fetus
- Allows fetal growth monitoring
- No known side effects
- Common methods
o Transabdominal
o Transvaginal
What is a nuchal translucency test?
- Part of enhanced first-trimester screening (eFTS)
- Screen for trisomy’s 13, 18, and 21
- Done between weeks 11-14
- US scans the translucent area on the back of the fetal neck measuring the diameter of the area
Describe an amniocentesis and what it can be used for
Generally, not offered unless
o Noninvasive screening test positive
o Maternal age at birth is ≥ 40 y/o
Procedure that obtains a sample of amniotic fluid
Genetic testing
o Amniotic fluid contains fetal cells that can be used to test for fetal abnormalities
Fetal lung maturity
o Can be determined in 3rd trimester
What are the 4 stages
First stage – Dilation and Effacement
Second stage – Delivery of Fetus
Third stage – Delivery of Placenta
Fourth stage – Recovery
How many cardinal movements of the fetus are there? What do these allow for? What are they?
7 movements
Allow for the baby to move through the birth canal
Movements are:
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- Restitution/external rotation
- Expulsion
MEMORY TRICK: Every Day Fetuses Incur Eviction Requests Early
Describe lightening
- Also called “dropping”
- Uterus drops into the true pelvis
- Nulliparous parents
o Noticeable change up to 4 weeks before end of term
o More frequently 38-40 weeks - Multiparous parents
o Tend to not drop until true labour is already in progress - Results
o Parent can breathe easier
o Pressure on bladder increases so urinary frequency occurs
What might women later in pregnancy experience lower body aches?
- Low back and sacroiliac distress
- Caused by pelvic joint relaxation
o Also called laxity
o More movement in areas that usually don’t move
o Occurs between the two parts of the symphysis pubis - May identify Braxton Hicks contractions
What is SROM? What may the woman experience?
Spontaneous rupture of membranes
* Also called “water breaking”
* This is the rupture of the amniotic sac
* Only occurs about 8% of the time
* High break results in a trickle of fluid
* Low break results in a gush of fluid
What is ripening?
Softening of the cervix that occurs before labour begins
What are the phases of the first stage of labour? How do we know which phase they are in?
Early labour
o 0-3 cm dilated
o Lots of effacement
Active labour
o 4-10 cm dilated
What can happen if SROM occurs but labour does not start? What is done in this case?
Increased risk of infection
Managed by
o Prophylactic antibiotics given
o If no labour after 18 hours, induction may occur
What does the pressure of the baby’s head cause to the mother at the onset of labour?
Cervical, uterine, and pituitary gland changes
What changes in maternal hormones occur at the onset of labour? What is the result of these changes?
Increased estrogen, oxytocin, and prostaglandins
* Prostaglandins are in semen so it will encourage cervical patients (sex also increases uterine contractions)
Decreasing progesterone
* Progesterone decreases myometrial irritability
Result in progressive uterine distension and increasing intrauterine pressure associated with increased myometrial irritability
Cause regular and rhythmic uterine contractions
What can happen if the mother begins to push before reaching 10 cm dilated?
Risk of massive cervical tear
About how fast does the mother dilate?
o Nulliparous are about 1 cm per hour
o Multiparous can happen much faster
When performing an admission interview, what is some information you need to know?
o Time labour started
o Frequency of contraction
o Pain location and intensity
o Vaginal discharge (bloody show) we use COAT
o Have membranes ruptured? If so, when?
When doing the physical assessment during admission of a pregnant woman, what do you need to assess?
Vaginal exam
- dilation
- SROM
Fetal assessment
- heart rate
- Leopold maneuver
When should you notify the care provider that a pregnant woman is here for an admission?
Once we determine they are in active labour and we are keeping them
What is some information about the birth plan we should ask about during admission?
o Identifies any risk factors we need to take into consideration
o Determine what the mother wants in terms of experience, pain management etc.
How are uterine contractions assessed?
Done by palpation at the fundus
Frequency
o Time (minutes) from the beginning of one contraction to the beginning of the next
o Generally the number of contractions in 10 min increments
Intensity
o Strength of a contraction at its peak
o Described as mild, moderate, strong
Duration
o Time (seconds) of one contraction from start to stop
Resting tone
o Tension of uterine muscles between contractions
Mild – slightly tense fundus – feels like tip of nose
Moderate – firm fundus – feels like chin
Strong – rigid fundus – feels like forehead
o Should be mild to moderate
o If it is strong, it can impact fetal perfusion and lead to fetal hypoxia
Baby usually grabs blood flow during the resting period
It’s why tachysystole is so bad
o This can only be done by palpation
How do we know the patient is 100% effaced?
Only a thin ridge of the cervix is felt
How do we know a patient has reached 10 cm dilated?
Cannot be felt anymore
What is the pneumonic for assessing the bloody show?
C – colour
O – odour
A – amount
T – time
What colour should the fluid be after the amniotic sac ruptures?
clear
What colours of ROM would be considered an emergency?
Red or green/brown
What does red in the fluid of ROM indicate?
A possible tear in the umbilical cord
What does does green/brown in the fluid of ROM indicate? What does that mean for this patient?
meconium, or “mec”
o Green/brown staining, it looks like pea soup
o First stool from baby that has built up while in the womb
o Should not be expelled until after birth
o If it occurs during labour, it is an indication of fetal distress
o If they inhale it, it can result in pneumonia
o Respiratory will need to be called down to aggressively suction them before they take their first breath
What is the procedure used to artificially rupture the membranes?
amniotomy
When assessing a contraction, what does the peak tell us? What are the risks of the peak not being strong enough?
o Will show intensity of the contraction
o Mild, moderate, strong
o If it is not strong, there will not be enough push down on the presenting part to get the dilation and effacement that we need
When assessing uterine contractions, what are we assessing resting tone for? What can it indicate if it is not an expected finding?
This can only be done by palpation
Tension of uterine muscles between contractions
Mild – slightly tense fundus – feels like tip of nose
Moderate – firm fundus – feels like chin
Strong – rigid fundus – feels like forehead
Should be mild to moderate
If it is strong, it can impact fetal perfusion and lead to fetal hypoxia
Baby usually grabs blood flow during the resting period
It’s why tachysystole is so bad
What is the average duration of the latent and active phases in the first stage of labour?
latent - 6-8 hours
active 3-6 hours
Describe the differences in contractions between the latent and active phases in the first stage of labour.
Latent
Strength - mild to moderate
Rhythm - irregular
Frequency - 5-30 min apart
Duration - 30-45 seconds
Active
Strength - moderate to very strong
Rhythm - more regular
Frequency - 2-5 min apart
Duration - 40-90 seconds
Describe the differences in the station of the presenting part between the latent and active phases in the first stage of labour. Does it change for nulliparous and multiparous patients?
Latent
Nulliparous: 0
Multiparous: -2cm to 0
Active
Nulliparous: +1 to +3 cm
Multiparous: +1 to +3 cm
What are the differences in the colour and amount of the show during the latent and active phases in the first stage of labour?
Latent
Brownish discharge, mucous plug, or pale pink mucous
Scant amount
Active
Pink-to-bloody mucus
Scant to copious amounts
Describe the behaviour and appearance of the mother between the latent and active phases of the first stage of labour
Latent
* Excited
* Thoughts center on self, labour and baby
* May be talkative or silent, calm or tense
* Some apprehension
* Alert, follows directions readily, open to instructions
Active
* Becomes more serious, apprehensive
* More doubtful of pain control
* Desires companionship and encouragement
* Attention more inner directed
* Fatigue evidenced
* Malar (cheeks) flush
* Some difficulty following directions
* Amnesia between contractions
* Writhing with contractions
* Nausea and vomiting, especially if hyperventilating
* Hyperesthesia
* Perspiration on forehead and upper lip
* Shaking tremor of thighs
* Feeling of need to defecate, pressure on anus
What should the nurse be aware of in terms of voiding for the labouring patient?
Urine
Encourage voiding
Avoid distended bladder as it can result in bladder rupture
Stool
* Over 70% of moms will have a bowel movement during labour
o Labour is a clean process, not a sterile process
o Just clean it up quickly and perform perineal care
* Suppositories and enemas NOT RECOMMENDED
Prophylactic enemas can result in contractions that are too strong
Describe some of the nursing actions in regards to ambulation of the labouring patient
o Encourage and support movement and changing positions
Walking
Swaying hips
Shower or bath
Sitting on exercise balls
Obviously unless an epidural was given as they will be confined to the bed after
Why are upright positions better for the labouring patient? What do these include? What is the best upright position?
Benefits
o Gravity helps
o Stronger but more efficient contractions helping with dilation and effacement
o Improved cardiac output
Includes walking, sitting, kneeling, squatting
A very deep squat is actually the best position for labour
The bottom of the bed actually comes away and there is a bar that can be hooked in that mom can hang off to sit in this position
What is the all 4s position? Why is it used for labouring patients?
o On hands and knees
o Used to relieve back pain
o Can also increase blood flow to baby in the case of decelerations
What nursing considerations are necessary with the use of epidurals in the labouring patients?
o Very effective for pain
o Unfortunately patients are bed bound after this
o Try to encourage movement even in the bed and don’t lay on the back
o High correlation for c-section in nulliparous patient
What is the fetal station?
Describes the degree of descent of the presenting part through the birth canal
The line between the ischial spines is considered 0
1 cm above the spines is -1, 1 cm below the spines is +1
Describe engagement. What fetal station is this? When does this occur?
o Indicates the largest transverse diameter of the presenting part has passed through the pelvic brim inlet into the true pelvis
o Usually corresponds with station 0
o Nulliparas – occurs in the weeks prior to labour
o Multiparas – may occur before or during labour
What fetal position is it “too late to push the baby back up”? What happens after this point is reached?
Engagement, or fetal station 0
We will go forward with a normal vaginal birth after this
What fetal station is indicated by the head being present but it sucks back into the maternal body between contractions?
+3 to +4
What fetal station is the baby at the perineum and no longer being sucked back into the mother between contractions?
+5
At what fetal stations is birth considered imminent?
+3 to +5
What are the 5 Ps? (factors affecting labour)
Passenger (fetus/placenta)
Passageway (birth canal)
Powers of contraction
Position (of labouring mother)
Physiological adaptations
Other than the 5Ps, what other factors can influence labour?
- Place of birth
- Preparation
- Presence of continuous labour support
- Type of provider
- Nursing care
- Procedure
What are some passenger (fetus) factors that can affect labour?
- Size of the head
- Presentation – the presenting part
- Lie – direction of baby
- Attitude – angle of the face in the pelvis
- Position
What are some passageway (birth canal) factors that can affect labour?
Bony pelvis
o True pelvis
Portion that is involved in childbirth
If we know the baby is too big for the pelvis, a recommendation may be given for an elective c-section
Soft tissues
o Includes
Lower uterine segment
Pelvic floor muscles
Vagina
Introitus
o Labour changes uterus
Bottom becomes thin and muscular
Top is thick and muscular
o Contractions push fetus against the cervix
o Considerations for scar tissue etc.
What are the two types of Powers of Contraction?
Involuntary or primary powers
o Responsible for effacement and dilation
Voluntary or secondary powers
o Begin after cervix has dilated
o Typically mom is at +1 or +2 fetal station
o We coordinate it with contractions
o Bearing down
What is Ferguson’s reflex?
o Urge to push or feeling need to have a bowel movement
o If mom doesn’t have this (i.e. epidural), sometimes doc will touch with a finger to show mom where to focus the pressure to
Describe the fetal heart rate adaptations during labour
Should be monitored
110-160 bpm
o Progressively decreases as the fetus matures closer to term
Temporary accelerations and slight decelerations are expected in response to
o Fetal movement
o Vaginal examination
o Fundal pressure
o Uterine contractions
o Abdominal palpation
o Fetal head compression
What is the fetal circulation affected by during labour
o Maternal position
o Contractions
o BP
o Umbilical cord flow
Describe fetal respiration adaptations that occur during labour?
Chemoreceptors stimulated in aorta and carotid artery to prepare fetus for initiating respirations resulting in
* Clearing of fetal lung fluid
* Decrease in
o Fetal oxygen pressure
o Arterial pH
o Bicarbonate levels
* Increase in arterial carbon dioxide pressure
Fetal respiratory movements decrease during labour
Describe the maternal adaptations to the cardiovascular system during labour
Heart rate increases
o Returns to pre-labour baseline within 1 hour after birth
Cardiac output increases
o Can be up to 51% above pre-labour baseline
o Peaks 10-30 minutes after birth
o Returns to pre-labour baseline within an hour
Changes in BP can be observed
Discourage woman from holder her breath during second stage
Describe the maternal adaptations to the respiratory system during labour
Greater oxygen consumption increases respiratory rate
o Consumption doubles in second stage
Hyperventilation can cause
o Alkalosis
o Hypoxia
o Hypocapnia
Anxiety can increase oxygen intake
Describe the maternal adaptations to the renal system during labour
Spontaneous voiding difficulty due to
o Edema caused by pressure from presenting part
o Discomfort
o Analgesia
o Embarrassment
Proteinuria up to +1 is normal due to muscle tissue breakdown caused by physical work of labour
Describe the maternal adaptations to the integumentary system during labour
- Stretching of tissues in area of vaginal introitus (entrance to vagina)
- Regardless, minute tears in skin around vagina introitus occur
- Temperature may rise but should resolve quickly after birth
Describe the maternal adaptations to the musculoskeletal system during labour
- Fatigue due to increased muscle activity
- Pelvic joint relaxation causes back pain
- Cramps
o Leg cramps may be caused by patients pointing toes during contractions
Describe the maternal adaptations to the neurological system during labour
Endorphins raise pain threshold and produce sedation
o Physiological anesthesia of perineal tissues caused by presenting part pressure decreases perception of pain
Changes in behaviour
o May start euphoric and become more serious later
o Amnesia between contractions during second state
o Elation and fatigue after giving birth
Describe the maternal adaptations to the GI system during labour
- Motility and absorption is deceased
- Nausea and vomiting of any undigested food consumed prior to labour onset
- Nausea and belching may occur as a response to full cervical dilation
- Diarrhea may occur at onset of labour
- Hard impacted stool may be in rectum that will often pass during pushing
Describe the maternal adaptations to the endocrine system during labour
Hormone changes during labour
o Increased estrogen, prostaglandins and oxytocin
o Decreased progesterone
Metabolism increases
Blood sugar may decrease
o Carefully monitor diabetic patients
Describe Group B Streptococcus (GBS) effects on pregnancy and neonates. How should this be managed?
Associated with poor pregnancy outcomes
Present in 10-30% of healthy pregnancies
Risk factors for neonatal infection
o Mother testing positive for GBS
o Prolonged rupture of membranes > 18 hours
o Interpartum maternal fever
To help reduce risk, IV antibiotics should be given after admission
When and how should fetal monitoring be performed
o Should be done intermittently for healthy term women
o Measured along with uterine activity (for context)
o Assessed 15-30 minutes
o Assess before and after ROM, and medical interventions
When is electronic fetal monitoring performed?
o Recommended when there is a high risk for adverse outcomes
o False belief that EFM can prevent negative outcomes
o Meant to assess fetal oxygenation continuously
What is internal fetal monitoring?
Device placed internally in the uterus, membranes must already be ruptured
Not interrupted by fetal movement
What is fetal tachycardia? What is it an early sign of? What conditions may cause it?
FHR > 160
Early sign of hypoxia
Can occur with
o Maternal fever (most common)
o Maternal or fetal infection
o Maternal hyperthyroidism
o Fetal anemia
o Medications
What is fetal bradycardia? What is it an early sign of? What conditions may cause it?
FHR < 110 bpm
Confirm the maternal heart rate is different
Bradycardia is not the same as prolonged decelerations
Can be caused by
o Fetal cardiac problems
o Infection
o Maternal hypoglycemia
o Maternal hypothermia
Describe fetal heartrate variability. What are the different levels?
Fluctuations in the baseline FHR that are determined in a 10 min segment
Does NOT include accelerations and decelerations
May be
o Absent: 0-2 bpm
o Minimal: ≤ 5 bpm
o Moderate: 6-25 bpm (this is considered normal)
o Marked: > 25 bpm
Describe accelerations
o Apparent and abrupt increase in FHR above the baseline
o At least 15 bpm
o Lasts 15 sec or more
o Could be in association with fetal movement
o Considered an indication of fetal health
Describe early decelerations
Considered normal
Caused by transient fetal head compression
Onset to lowest point is ≥30 sec
Mirrors moms contractions
Take the top of moms contractions and it is the same place as the babies deceleration
This is good because this means that baby is coming down the birth canal
How are decelerations described in order to determine if they are abnormal or benign?
In relation to the timing of the contraction
Describe late decelerations
Associated with contractions and begins after contractions start
Onset to lowest point is ≥ 30 sec and well after the peak of contraction
Have a long slow U shape to them
Persistent and repetitive decelerations are a concern when they are uncorrectable
Caused by uteroplacental insufficiency
Describe variable decelerations
Most common type
Onset to lowest point is < 30 sec so abrupt, leaving a distinct V shape rather than the U shape of late decelerations
FHR decreases at least 15 sec but less than 2 min
Occur during or between contractions
Cause by umbilical cord compression
Could cause fetal hypoxia
Describe prolonged decelerations
At least 15 bpm below baseline and lasting >2 min but <10 min
When decelerations last > 10 min it is considered a baseline change
Causes include
* Prolonged fetal hypoxia
* Prolonged or extreme uteroplacental insufficiency
* Prolonged cord compression, prolapse, or entanglement
* Maternal hypotension
* Cervical exam
* Uterine tachysystole or rupture
When is artificial membrane rupture contraindicated?
Placenta previa
Breech position
What is considered failure to progress through the first stage of labour? Is it different for nulliparous patients than for multiparous patients?
Nulliparous
Latent >20 hours
Active <1.2 cm/h cervical dilation
Multiparous
Latent >14 hours
Active < 1.5 cm/h cervical dilation
About how quickly do most women dilate during the active phase of the first stage of labour?
About 1 cm per hour
When the amniotic fluid is examined, there may be white flecks in it, what is this?
Vernix caseosa
Is the waxy substance baby’s are covered in
Babies shed this as they come close to term
Premie babies are covered in it
Overdue babies are wrinkly because they don’t have it any more to protect them
What is a normal amount of PPH?
<500 mL blood loss
What are the symptoms of impending birth?
Urge to push/defecate
Crowning
What are the 3 R’s of childbirth?
3 characteristics pregnant women use to cope well
Relaxation
o Relaxing between contractions
o Later they may have a hard time so even just move or vocalize
Rhythm
o Use of rhythm
Ritual
o Repeated use of personally meaningful rhythmic activities with every contraction
When looking at a FHR tracing, who is represented by the two lines?
Baby is the top, mom is on the bottom
What is memory trick for remembering the names and causes of types of changes in the FHR?
VEAL CHOP
- Variable———–Cord compression
- Early —————Head compression
- Accelerations—-Ok
- Late —————-Placental insufficiency
Describe the pain experienced during the first stage of labour. What is it caused by? Where can it radiate to?
Predominantly visceral pain over lower portion of the abdomen
Caused by
o Dilation of the cervix
o Pressure on adjacent structures
o Hypoxia of uterine muscles during contractions
o Stretching of lower uterine segment
Referred pain from the uterus may radiate to
o Abdominal wall
o Lumbosacral area of the back
o Iliac crests
o Gluteal area
o Thighs
What are some of the physiological factors that affect pain perception during labour?
- Scarred cervix
- Fatigue
- Interval and duration of contractions
- Fetal size and position
- Rapidity of fetal descent
- Maternal position
What are some of the sensory factors that affect pain perception during labour?
Nulliparous patients
o Greater pain during early latent labour (dilation <4 cm)
Due to reproductive tract structures are less supple
Multiparous patients
o Greater pain during active labour
May be due to increased speed of fetal descent
What are some of the affective factors that affect pain perception during labour?
Excessive FEAR and anxiety associated with increased pain in labour
Causes catecholamine secretion increasing stimuli to brain from pelvis
The result is
Increased muscle tension
Decreased effectiveness of uterine contractions
Increase in experience of discomfort
Further increases fear and anxiety making a positive feedback loop
Slowed labour progression (Catecholamine inhibits oxytocin secretion)
What are some of the factors that can affect a labouring mothers perception of pain during labour?
- physiological
- sensory
- affective (FEAR!)
- cognitive (education)
- behavioural
- sociocultural factors
- supportive care
Describe supportive care for a labouring mother. Who may be this support person? What benefits does an effective support person provide to the labouring mother?
It is recommended that all women in active labour have continuous 1-1 labour support
May be a trained person (doula) or a friend or family member of the woman’s choice (even if they have no childbirth experience)
Includes continuous presence, emotional support, comfort measures, advocacy, information, and advice
Benefits
o Increased likelihood of vaginal delivery
o Decreased risk of c-section
o Reduced use of epidural analgesia
o Increased Apgar score
o Increased maternal satisfaction
Describe maternal physiologic responses to the pain experienced in labour
Cardiac output
o Increases with pain from contractions and anxiety
Blood pressure
o Increases during contractions and may increase with pain
Respiratory system
o Oxygen demand and consumption increases
o Respiration and pulse increase with pain
Musculoskeletal system
o Decreased oxygen supply to muscles increases pain
Immune system
o Increase in WBC
Blood values
o Maternal BGL decreases
Is the labouring mother allowed to eat during labour?
- Patients should not eat solid foots once in established labour due to decreased gastric emptying
- Clear liquids are emptied much faster
- Low risk patients
o Evidence says allowing them to eat during labour may shorten length of labour and does not increase obstetrical risk
What nonpharmacologic comfort measures can be used in early labour to help with the pain?
Maternal ambulation and position change
o Upright and gravity enhancing positions
o Rhythmic motion
o Change position frequently
Distraction may employ gate-control theory of pain so try
o Cutaneous stimulation strategies
o Sensory stimulation strategies
o Cognitive strategies
What are some examples of cutaneous stimulation strategies that can be used to help provide comfort during early labour?
Counterpressure
Effleurage (light massage)
Therapeutic touch and massage
Walking
Rocking
Changing positions
Application of heat or cold
TENS machine
Acupressure/acupuncture
Hydrotherapy (showers, bath)
Intradermal water block
What are some examples of sensory stimulation strategies that can be used to help provide comfort during early labour?
Aromatherapy
Breathing techniques
Music
Imagery
Use of focal points
What are some examples of cognitive strategies that can be used to help provide comfort during early labour?
Childbirth education
Relaxation
Hypnosis
Biofeedback
Describe opioid use during labour. Include examples and side effects
- Cross the placenta
- Rapid onset with short duration
- Administer only once labour is well established
Includes
o Fentanyl
o Sufentanil
o Morphine
Side effects include
o Decreased uterine contractions
o Nasua and vomiting
o Respiratory depression
o Maternal and neonatal CNS depression
Describe nitrous oxide use during labour including benefits and side effects
- Self-administered via a demand valve
- Can be used in combination with other forms of pain relief
- Results in a sense of euphoria and decreased anxiety
- Begin inhaling 30 seconds prior to contractions to achieve peak with contraction peak
Benefits
o Safe for baby and does not accumulate in fetal tissues
o Does not affect uterine activity
o Rapid onset, fast clearance
Side effects
o Nausea and vomiting
Describe an epidural block
- Anesthetic or opioid injected into the epidural space
o Drug type, amount and combination result in varying degrees of motor impairment
o A combination of both is often used to achieve desired pain relief but retaining the largest degree of motor function
o Goal is to provide sufficient anaesthesia with as little blockage to the sensory and motor nerves as possible
What are the benefits of using an epidural block
o Considered to be the most effective and flexible method of pain management for labour
o Promotes good relaxation
o Mother remains fully awake, and airway reflexes remain intact
o Mom is more comfortable and remains able to participate in the birth
o Does not delay gastric emptying
o Motor paralysis is mild
What is dystocia? How can an epidural help?
o Delayed or arrested progress in labour, irrespective of causes
o Epidural can provide benefits for this if they require augmentation
Although epidurals can prolong labour if administered before the labour is will established
Describe the side effects of using a epidural during labour? Include maternal and fetal side effects.
o May prolong labour if administered before labour is well established
o May interfere with mobility (walking during first stage)
Maternal
* Hypotension
o Can result in decreased uteroplacental perfusion and reduced oxygen delivery to the fetus
* Nausea, vomiting
* Fever
* Pruritis
o Common with opioids
* Intravascular injection
* Respiratory depression
* Post partum urinary retention and stress incontinence
o May be related to the epidural or catheterization done in labour
o May be related to use of forceps or vacuums used during labour
Fetus
Fetal distress secondary to maternal hypotension
What negative complications to labour can epidurals increase the incidence of?
Longer second-stage labour
Fetal malposition
Use of oxytocin
Forceps or vacuum assisted birth
What types of pain management medication can be used during the first stage of labour?
- Systemic analgesia
o Opioid agonist analgesics
o Opioid agonist-antagonist analgesics - Epidural (block) analgesia
- Combined spinal-epidural (CSE) analgesia
- Nitrous oxide
What types of pain management medication can be used during the second stage of labour?
- Nerve block analgesia/anesthesia
- Local infiltration anesthesia
- Pudendal block
- Epidural (block) analgesia and anesthesia
- Spinal (block) anesthesia
- Nitrous oxide
What types of pain management medication can be used during C-sections?
- Spinal (block) anesthesia
- Epidural (block) anesthesia
- General anesthesia
What are the nurse’s role when using epidural anesthesia?
- Monitor the status of the patient receiving regional anaesthesia, the fetus, and the progression of labour
- Replace empty infusion syringes or bags with the same medication and concentration
- Stope the infusion if there is a safety concern or the patient has given birth
- Remove the catheter if properly educated to do so
- Initiate emergency measures if the need arises
- Communicate clinical assessments and changes in patient status to obstetrical and anaesthesia care providers
- Alter rate of medication infusion and administer bolus doses as ordered
What are the 2 phases of the second stage of labour?
Passive phase
o Baby making the cardinal movements to get into place
o It’s a holding pattern for mom
o Don’t have mom push until she has an urge to push
Tricky with an epidural as this sensation may not exist
Active pushing (descent) phase
When does the second stage of labour begin and end?
- Begins with full cervical dilation and complete effacement and ends with baby’s birth
How long does the second stage of labour last? What are factors that can affect the length of this stage?
Can range from 2 hours to 30 minutes
Factors that affect length include
* Epidural anaesthesia (reduces urge to bear down and limits ability to get into an upright position to push)
* Patients age
* BMI
* Emotional state (FEAR is the biggest issue!)
* Adequacy of support (Someone who is experienced and supportive is really helpful here)
* Level of fatigue
* Fetus: cephalopelvic disproportion due to head size, position, and presentation
What is a precipitous delivery?
o Very fast <3 hours from onset of regular contractions
o If they have a history of it they are likely to have that happen again
What is slow progression of the second stage of labour? Does this change with nulliparous vs multiparous? How does regional anesthesia affect it?
Nulliparous
o ≥3 hours with no regional anaesthesia
o ≥4 hours with regional anaesthesia
Multiparous
o ≥2 hours with no regional anaesthesia
o ≥3 hours with regional anaesthesia
If a stat C-section is required, what pain relief is used and what effect does this have on the ability for the partner to be in the delivery suite?
If epidural is in place
o More drugs given through it for pain relief for the c-section
o Partner is allowed to be in the room
If no epidural is in place
o General anesthesia is provided
o Anesthesiologist has to control the airway so the partner has no room to be there
What are signs of the onset of the second stage of labour?
Ferguson’s reflex
o Urge to push or feeling need to have a bowel movement
o If mom doesn’t have this, sometimes doc will touch with a finger to show mom where to focus the pressure to
Shaking of extremities
Sudden appearance of sweat on the upper lip
Episode of vomiting
o We discourage heavy eating because it will come back up
o Fight or flight, don’t got enough time for it
Increased bloody show
Increased restlessness, may verbalize they can’t continue etc.
Involuntary bearing-down efforts
Describe crowning. What station does this occur in and what does this mean for mother?
- Occurs when the top of the head no longer regresses between contractions
- The widest part of the head distends the vulva just before birth
+4 station they will still be sliding back and forth
o We don’t want to have mom push at +4 too much as it can cause significant tearing
o It is very painful
o We can have mom pant, because she can’t pant and push at the same time
+5 station they are staying there between contractions
o Ready to push when mom is
During the second stage of labour, how often are we assessing mom, baby, and labour progression? What are we looking for with each assessment?
Mom every 5-30 min
o BP, pulse, respirations
Fetus every 5 min
o Heart rate and pattern
Labour progression every 10-15 min
o Vaginal show
o Signs of fetal descent
o Changes in maternal appearance, mood, affect, energy level
o Condition of support person
o Contraction and bearing down effort
What are the nursing actions during the passive phase of the second stage of labour?
- Help patient to rest in a position of comfort
- Encourage relaxation to conserve energy
- Promote progress of fetal descent and onset of urge to bear down by encouraging position changes, pelvic rock, ambulation, and showering
What are the nursing actions in the active (descent) phase of the second stage of labour?
- Help patient change position and encourage spontaneous bearing-down efforts
- Help patient to relax and conserve energy between contractions
- Provide comfort and pain-relief measures as needed
- Cleanse perineum promptly if fecal material is expelled
- Coach patient to pant during contractions and to gently push between contractions when the head is emerging
- Provide emotional support, encouragement, and positive reinforcement of efforts
- Keep patient informed regarding progress
- Create a calm and quiet environment
- Offer mirror to watch birth or encourage patient to feel top of fetal head as they are pushing
What is perineal trauma?
- Vaginal and urethral lacerations
- Cervical injuries
How does fear/anxiety affect the second stage of labour?
Fear is one of the biggest barrier to natural childbirth
Fear and anxiety can increase risk of perineal trauma
What are risk factors for perineal trauma during the second stage of labour?
- Baby’s face is up
- Baby’s shoulder is stuck
- Breech delivery that gets a little hung up
- Very large baby
- Using forceps or assistive use devices
- History of cephalopelvic disproportion
- Parity
o Nulliparous are likely to have a longer second stage increasing swelling in the perineal area increasing risk of tear
o Multiparous are more likely to have a precipitous delivery which doesn’t allow time for the introitus to stretch on it’s own - Maternal position
o Upright allows for gradual stretching from downward pressure
o Supine or side lying for the majority of second stage doesn’t allow for this - Emotional response
o Fear and anxiety can increase risk - Previous tears
o 3rd and 4th degree tears previous can tear down the same line (c-section may be offered in these more severe cases)
What are some risk reduction techniques for perineal trauma or the need for an episiotomy?
- Perineal massage with lubricant
o Can be done after 34 weeks
o Pushing down on the bottom of the vaginal opening - Warm compress
- Kegel exercises
- Knowing the risk factors
- Mother in upright position in second stage
Describe the different levels of perineal lacerations
First degree
o Extends through the skin
Second degree
o Extends through the muscles of the perineal body
Third degree
o Continues through the anal sphincter muscle
o Can happen with the use of forceps or pushing at only +4
o Repairs are significant with multiple layers involved
o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis
o May require a pudenda block
Fourth degree
o Involves the anterior rectal wall
o Can happen with the use of forceps or pushing at only +4
o Repairs are significant with multiple layers involved
o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis
o May require a pudenda block
What types of perineal lacerations require significant repair with multiple layers of tissue involved?
3rd and 4th degree
Why are third and fourth degree considered so significant?
Third decree includes the anal sphincter and fourth involves the anterior rectal wall
o Can happen with the use of forceps or pushing at only +4
o Repairs are significant with multiple layers involved
o If not repaired correctly, they may end up with fistulas which can result in massive side effects including sepsis
o May require a pudenda block
What is the pudendal nerve? Why might a tear require a block to this nerve?
Pudendal nerve provides most of the movement and sensations for the pelvic region including the external genitals and anus. 3rd and 4th degree tears may need a pudenda block for pain relief and tear repair unless a spinal block/epidural block are already in place
Where is the perineal trauma clinic? Who is referred here and what treatments are done?
At the Alex
* 3rd and 4th degree tears automatically referred
* They do Kegel exercises to increase muscle strength to the area as part of physio
What is an episiotomy?
Surgical incision of the perineum to enlarge the outlet
o Conversation about cut vs tear
o Routine are no longer recommended
Procedure
o We go medio-lateral now rather than midline
This way if there is tearing beyond the cut, it doesn’t involve the anal area
What are complications of an episiotomy/perineal trauma?
o Bleeding
o Infection
o Painful intercourse
o Injury to anal sphincter and rectum
o Scarring
o Urinary incontinence
o Prolonged recovery time
What are the sources of pain during the second stage of labour?
Perineal pain is the primary cause of pain
o Distension of vagina and perineum
Stretch receptors
o Located on the pelvic floor
o Stimulates release of oxytocin from the posterior pituitary gland resulting in more intense contractions
o This is where Ferguson’s reflex comes from
Pressure on adjacent structures
Hypoxia of contracting uterine muscles
When in the second stage of labour, the nurse performs ongoing assessment of the labour and labour progress. What would the nurse be looking for?
Labour
o Contractions
o Fetal response (FHR q5min when pushing)
o Amniotic fluid
Labour progress
* Assessing progress of labour q 10-15 min
o Vaginal show
o Signs of fetal descent
o Bulging
o Crowning
Coping during the second stage of labour is important, what would the nurse continual assess for in regards to coping?
Maternal coping
o Mood
o Affect
o Energy level
o Pain management
Partner’s coping
What would some considerations be for the nurse providing assistance with positioning during the second stage of labour?
o Squatting works best to bring baby down and stretch the perineal area
o On all 4s is best to help get baby shift position
o Supine position is the worst position
Prolongs second stage
Increases need for assistive devices
May be the only position in a epidural
When the mother is actively pushing, how may the nurse help her patient?
Encourage to push as she feels like pushing
o Instinctive spontaneous pushing
Encourage open glottis bearing down
o Preferred method
o Maternal grunting or groaning when pushing
o Allows air to be released while pushing
o Helps maintain adequate oxygen levels for mom and baby
o About 5 pushes of about 5 seconds long per contraction
Why do we avoid giving the mother a command for a prolonged push during a contraction? (Like the good old hold for 10 second count we used to see on TV). What are adverse effects of this type of pushing?
o These are the old hold the breath and push for 10 seconds
o Directed, closed glottis pushing
o While still widely used, it can trigger Valsalva manoeuvre due to the increase in thoracic pressure
Adverse effects
Fetal hypoxia and subsequent acidosis
Increased risk of pelvic floor damage
Increased risk of perineal trauma
When does the 3rd stage of labour begin and end? How long is it?
- Lasts from birth of the baby until the placenta is expelled
- Generally occurs within 15 minutes of the birth of the baby
What occurs when the third stage of labour has not been completed within 30 minutes after the birth of the fetus? What interventions may be instituted?
Retained placenta
Interventions to hasten its separation and expulsing are usually instituted at this point and they include:
* Gentle cord traction
* Manual removal
o Someone reaches in and gently pulling the placenta off the uterine wall
o Is only done if they have an epidural
* Surgical
o D&C to remove the placenta
What are signs that the placenta is about to be expelled?
- Firmly contracting fundus
- Change in the uterus from a discoid to a globular oval shape as the placenta moves into the lower uterine segment
- Sudden gush of dark blood from the introitus
o Normal and not a concern as long as it’s associated with the placenta releasing - Apparent lengthening of the umbilical cord as the placenta descends to the introitus
- Vaginal fullness (the placenta) noted on vaginal examination or of fetal membranes at the introitus
What type of management of the 3rd stage of labour is generally done with home births and midwifes? What does this generally involve?
Passive management
o Wait for signs the placenta has separated spontaneously
o Monitors for spontaneous expulsion
o May involve gravity or nipple stimulation to facilitate expulsion
o Quiet, relaxed environment supports skin-to-skin contact
o Promotes endogenous oxytocin release
o No oxytocin is given
How long after the birth of the fetus is the cord clamped? If the birthing mom wants to do delayed cord-clamping, how long do we wait?
within 30 seconds
Delayed is 1-3 minutes
Describe the management recommended by the WHO for separation and expulsion of the placenta.
Active management
o Decreases rates of PPH due to uterine atony
o Oxytocin is given after birth anterior shoulder
o Clamp and cut cord within 3 minutes of birth
o Gently controlling cord traction following uterine contraction and separation of the placenta
What are some nursing interventions that can be done during the 3rd stage of labour?
- Assist patient to bear down to facilitate expulsion
- Administer oxytocin as ordered to ensure adequate contraction of the uterus to prevent hemorrhage
- Provide nonpharmacological and pharmacological comfort and pain-relief measures
- Perform hygienic cleansing measures
- Keep patient informed of progress of placental separation and expulsion and perineal repair, if appropriate
- Explain the purpose of medications administered
- Introduce parents to their baby and facilitate the attachment process by delaying eye prophylaxis and other tasks like weighing and measuring the baby
- Cover parent and baby together for skin-to-skin contact
- Provide private time for parents to bond with their new baby
- Encourage breastfeeding when newborn shows signs of interest
How do we prevent post partum hemorrhage?
Active management of third stage of labour
o Reduces risk of PPH and should be offered and recommended to all women
IM Oxytocin
o 10 IU
o IM is best for low-risk deliveries
o Should be administered after delivery of fetuses anterior shoulder
IV Oxytocin
o Used if IM is not indicated
o 20-40 IU in 1000 mL infusion at 150 mL per hour
If the uterus is boggy, perform fundal massage
If hemorrhage continues, it is likely due to retained products
When does blood collection occur? What can it be used for?
Occurs before placenta separates from maternal uterus
Used for
o ABG and VBG
o Blood type, especially if mother is Rh negative
Once the placenta is delivered, it has two different sides. What are they, and why would they be how the placenta presents as it is expelled from the uterus?
“Shiny side”
o Fetal side presents
o Grey and shiny in appearance
o Occurs when placenta separates form the inside to the outside margins
“Dirty side”
o Maternal side presents
o Surface is rough and red
o Occurs when placenta separates from the outside margins inward
It basically rolls up and presents sideways, maternal side first
When is the fourth stage of labour? What are our priorities at this time?
- 1-2 hours after birth (sometimes 4 hours depending on source)
- Immediate care of mother and newborn
Monitor mother for
o Hemorrhage
o Bladder distension
o Venous thrombosis
How often are vitals completed during the first hour of the fourth stage of labour? What is expected?
Every 15 min
o BP returns to pre-labour values
o Pulse will be lower than during labour
How often do we take temperature after the birth of the baby? What are expected changes?
Every 4 hours
o May increase minimally in first 24 hours
Due to increased work of effort during prolonged labour
Exacerbated by dehydration
o As long as it goes back to normal after 24 hours it is considered normal
How do we assess the uterus during the 4th stage of labour? What are we assessing for?
Assess for tone (firmness) by palpating the fundus
o Bogy - Uterus is soft (uterine atony)
Massage to express retained clots
Height measured in cm from the umbilicus
Above the umbilicus is a positive value, below is negative
Decreases 1 cm per day, about 7-10 days is back in the pelvis
Should be midline
If it is up and right it means bladder is distended
* This prevents proper uterus contractions to bring it back to a small size and the uterus will continue to bleed
What is the term for post partum bleeding?
Lochia
When assessing for the lochia, what are we looking for?
- Measure % of pooling of blood under the buttocks
- Inspect bloody vaginal discharge
- Monitor for clots (size and consistency)
- Chart amount (scant, minimal, moderate, heavy)
- Chart colour (red, pink, white)
What assessing lochia for clots, what is considered normal? What indicates retained product?
Normal
< 1 cm
Gelatinous feel
Retained product signs
> 1 cm
Fleshy feel
When looking at amount of lochia after the birth of the baby, how are we assessing it and how would we charge it?
o Turn mom onto her side to ensure that we are seeing any blood that is pooling at her bottom and missing the pad
o Normal < 500mL
Scant - <2.5 cm stain
Light - 2.5-10 cm stain (may see this with c-sections)
Moderate - 10-15 cm stain (normal for first 1-2 hours)
Heavy - full pad saturated in 1 hour (should not happen)
While many start as moderate for the first few hours, they should continue to decrease in amount after that
What teaching should the new mother be given in regards to the amount of lochia she has after discharge?
o When mom is discharged, we have her monitor the bleeding for the next 3-4 weeks and it should be decreasing over time
If there is a saturation of a pad <1 hour they need to come in right away
Describe lochia rubra
Dark red discharge
From birth to 3-4 days post-partum
Flow in amounts like a heavy menstrual period
May have small clots
Odour should be fleshy, like menstrual blood
Describe lochia serosa
Pinkish-brownish discharge
From 4 days to 12-14 days post-partum
Flow is moderate to small amount
Describe lochia alba
Yellowish white discharge
From 12 days to 3 weeks postpartum
Gradually disappearing scant creamy whitish discharge
If the postpartum mom overexerts herself or experiences significant stress, what can happen to the lochia she observes?
May increase amount or change the colour i.e. serosa back to rubra
When providing perineal care during the 4th stage of labour, what steps should be taken and what should be assessed for?
Steps:
* Wash with warm water, dry well, and apply sanitary pad
* Provide ice pack against perineum to promote comfort and decrease swelling
* When assessing the perineum, have the woman lie on her side
Laceration/episiotomy repair evaluation: GRACED with a new baby
G - Goose egg - Hematoma
Causes lots of discomfort
Suspect it even if you can’t see it
Usually caused by a vessel that was missed in a repair
May need a repair
R - Redness
A - Approximation
C - Contusion
E - Edema
D - Discharge
Also look for hemorrhoids
Once we have evaluated the uterus in the 4th stage of pregnancy, we should assess for the presence of bladder distension. How is this done? What is it associated with? How can we manage it?
Assess firmness of uterine fundus then observe and palpate bladder
o Noted as suprapubic rounded bulge
o Fluctuates like a water-filled balloon
o Dull to percussion
Often associated with uterus that is
o Boggy
o Well above the umbilicus
o Deviated to the patient’s right side
o This actually prevents the uterus contractions we need to stop the hemorrhaging
Management
* Assist patient to void spontaneously
o Measure amount of urine collected
* Catheterize as necessary
* Reassess after voiding/catheterization
o Ensure bladder is not palpable and fundus is firm and midline
